Food keeps sticking

• Eight weeks of steadily worsening symptoms. Meat and bread stuck first; now some softer foods do too.
• Swallowing starts normally. Food seems to stop behind the lower breastbone. Water passes.
• No current impaction, drooling or difficulty swallowing saliva. No immediate coughing, nasal regurgitation, painful swallowing or new neurological symptoms.
• Occasional regurgitation shortly after eating. No haematemesis or melaena.

Weight fell from 82 kg to 76 kg unintentionally. Appetite remains, but fear of sticking limits meals. During the last week he has eaten approximately half his usual amount: small portions of porridge, smooth soup and yoghurt. He drinks approximately 1.5 litres daily. There have been no days with completely absent intake, reduced urine output or postural dizziness.

Longstanding reflux; omeprazole improved burning but not swallowing. Hypertension treated with amlodipine 5 mg daily; omeprazole 20 mg daily. No anticoagulants, relevant surgery or known allergies. Former smoker, 25 pack-years. Lives with his wife.

“My father died of cancer. I’m frightened that finding something means nothing can be done.”

“I have a holiday in three weeks. Could we try stronger tablets and investigate afterwards?”

Roleplayer: become more receptive when the candidate acknowledges fear, explains uncertainty honestly and offers practical support. Do not immediately agree merely because “urgent” is repeated.

Ask permission, preserve dignity and explain the purpose of a focused examination. Do not ask the patient to swallow a solid bolus to demonstrate the problem.

“This is progressive oesophageal dysphagia, predominantly affecting solids, with substantial recent weight loss and reduced intake. A structural cause is my leading concern. Cancer must be excluded, but reflux-related narrowing remains plausible. He currently maintains fluids and saliva, so there is no evidence of complete obstruction.”

Normal initiation and retrosternal sticking support an oesophageal pattern, although the perceived site is not an exact anatomical locator. Rings and eosinophilic oesophagitis more often produce intermittent solid-food symptoms or impaction. Motility disease becomes more likely when solids and liquids are affected from the outset, but patterns are not absolute.

Arrange a suspected cancer pathway referral, usually leading to upper gastrointestinal endoscopy and appropriate tissue sampling. Dysphagia itself meets NICE NG12 recommendation 1.2.1; weight loss is not required. Do not delay referral for blood tests or another acid-suppression trial.

• FBC: assess anaemia and other haematological abnormalities.
• Urea, creatinine and electrolytes: assess consequences of reduced intake and guide correction if needed.
• Liver profile: useful baseline where clinically indicated; neither excludes nor stages cancer.
• Magnesium and phosphate: add when nutritional assessment identifies depletion or refeeding risk, not automatically.

These are supporting, case-specific investigations, not a mandatory referral panel. Normal results do not cancel the referral.

Document weight trajectory, actual intake and expected restriction; use validated nutritional screening. Arrange timely dietetic support and tolerated nutrition, without forcing foods that stick. Do not prescribe automatic thickening for an oesophageal symptom pattern.

Arrange a short-interval review of intake and referral progress, for example within several days and sooner if deterioration occurs. This is a proposed case plan, not a nationally mandated deadline. Assign a named clinician or team to track the appointment and biopsy results.

“The pattern suggests that food may be meeting a narrowing in the food pipe. Scarring from reflux is one possibility, but a growth is another, so I cannot safely assume this is simply acid reflux. I understand why your father’s experience makes this frightening. We have not diagnosed cancer, and we cannot predict treatment or outlook before investigating. I recommend investigating promptly rather than waiting until after your holiday. We can discuss appointment arrangements and what support would make the test manageable.”

A flexible camera examines the food pipe and stomach and permits biopsies. Discuss throat spray and possible conscious sedation, which is not normally a general anaesthetic. Explain discomfort or gagging, uncommon bleeding or perforation, aspiration and sedation-related complications, and the possibility of a missed abnormality. Sedation requires an escort and restrictions afterwards, following the unit’s instructions.

If he declines, explore discomfort, fear of the result and practical arrangements. Discuss options with gastroenterology, including alternative imaging where appropriate; imaging cannot provide an endoscopic biopsy. Respect an informed decision, document it and maintain follow-up. Check understanding by asking him to explain the agreed plan in his own words.

• Cannot swallow saliva after a meal: possible complete obstruction; urgent emergency assessment, not routine outpatient follow-up. Do not force oral intake.
• Very poor fluid intake, dizziness or reduced urine: urgent reassessment for dehydration and possible hospital support.
• Solids and liquids affected from the beginning: reconsider motility disease while still excluding structural causes.
• Immediate choking with sudden dysarthria: consider acute neurological or oropharyngeal pathology and escalate urgently.
• Breathing difficulty, major bleeding or collapse: emergency help.

An old examination describes the situation then, not the cause of new progressive symptoms now. Check the original report and any biopsies, but do not let retrieving it delay the current urgent referral. Explain the distinction between prior reassurance and a changed clinical problem.

Ask what happened and what would make the procedure manageable. Acknowledge the distress, discuss throat spray and sedation options with the endoscopy team, and explain how consent and stopping the examination are handled. Do not promise a completely sensation-free test or general anaesthesia. Check escort and transport arrangements if sedation is chosen. If he declines, discuss the benefits and limitations of alternatives with gastroenterology, document the informed decision and retain a clear follow-up plan.

Explain that the referral is urgent but do not guarantee an individual appointment, biopsy result or diagnosis date. Confirm who tracks the referral and results, how he can make contact if nothing arrives, and what deterioration requires urgent help. Explore postponing travel rather than implying a timetable can remove the clinical risk.

Strong: Establishes progression, solids/liquids, saliva tolerance and actual intake.

Incomplete: Identifies dysphagia but leaves severity unclear.

Unsafe: Misses inability to swallow saliva.

Strong: Prioritises structural disease while retaining uncertainty.

Incomplete: Lists diagnoses without prioritisation.

Unsafe: Reassures because examination is normal.

Strong: Urgent referral, nutrition assessment and tracked follow-up.

Incomplete: Referral alone without interim support.

Unsafe: Delays investigation for a PPI trial.

Strong: Explores cancer fear and negotiates next steps.

Incomplete: Correct information without addressing fear.

Unsafe: Declares cancer established or coerces consent.

Strong: Focused, respectful and correctly interpreted.

Incomplete: Performs an unexplained checklist.

Unsafe: Invents signs or provokes obstruction.

• The timing of difficulty relative to the swallow is more useful for localisation than where the patient points.
• Progression from solids towards liquids favours a narrowing process; solids and liquids from the outset makes motility disease more likely, although patterns are not absolute.
• Dysphagia itself meets the NICE suspected cancer pathway criterion; weight loss strengthens concern but is not required.
• A normal examination and improvement in heartburn do not safely exclude an oesophageal lesion.
• A PPI trial must not delay investigation of progressive dysphagia.

Repeat the consultation with only two initial discriminators: whether swallowing is difficult to initiate, and whether symptoms began with solids alone. Then deliver a 60-second explanation that names uncertainty, the urgent referral, endoscopy choices and the safety-net without promising a diagnosis date.